[104-10222-10040.pdf — page 74]
# HEALTH BENEFITS REGISTRATION FORMStandard Form No 2FHO(MARI-FPM)(AUGUST 1969)*PRESCR. 26.M.S.FSRS HEALTH BENEFITS ACT OF 1959**1. Indicate type of Use only permanent or temporary employee*CARRIER S. (FMHIIA FPM)153281**PART A**ALL WHO REGISTERMUST FILL IN THIS PART.1. NAME (Last) (First) (Middle Initial) 2. DATE OF BIRTH 3. Are you employed?SHAW ROBERT T. 6 18 254. YOUR MAILING ADDRESS (Number and street) (City and Zone number) (State) 5. SEXBOX 1447, WILLIAMSBURG, VA6. Are you covered by, or is anyone in your family listed below com- 7. Place an "X" in proper box to show your annual basic salary range.covered by or enrolling in, a plan under the Federal EmployeesHealth Benefits Act of 1959 (through the enrollment of anotherUnited States or District of Columbia Government employee orannuitant)?Yes [ ] No [X]Up to $4,000 [ ]$6,000 to $9,999 [X]$4,000 to $5,999 [ ]$10,000 of over [ ]**PART B**FILL IN THISPART IF YOUWISH TO EN-ROLL IN AHEALTH BENEFITSPLAN.1. I elect to enroll in a health benefits plan as shown below. I authorize deductions to be made from my salary, compensation, or annuity   to cover my share of the cost of the enrollment. (Copy the information requested below from inside cover of brochure of the plan you select.)NAME OF PLANOPTION (HIGH OR LOW)2. In space below list all eligible family members, without exception: List your wife or husband first, if none your unmarried children under   age 19, including legally adopted children and stepchildren and illegitimate children who live with you in a regular parent-child relationship.   If no children give names of parents, brothers and sisters. Give date of birth of each person listed. If unmarried child is age 19 and who, because of disability, is incapable   of self-support. (Furnish a doctor's certificate for a disabled child age 19 or over.)NAMES OF FAMILY MEMBERSDATE OF BIRTH (Month, Day, Year)Wife or Husband [ ][ ][ ][ ][ ]**THIS PART MUSTALSO BE FILLEDIF YOUCHANGE YOURENROLLMENT.**3. If you are a female (employee or annuitant), does the family listed above include a husband who is incapable of self- Yes [ ]   support by reason of mental or physical disability which can be expected to continue for more than one year? (If answer   is "Yes," furnish a doctor's certificate.)   No [ ]**PART C**FILL IN THISPART IF YOUWISH NOT TOENROLL OR IFYOU WISH TOCANCEL YOURENROLLMENT.PLACE AN "X" in item 1 or item 2, and also answer item 31. I elect not to enroll in any plan under the Health Benefits Act. [X] 3. The reason for my election is (Place an "X" in proper box):(a) I am covered by a plan under the Health Benefits Act through the enroll- [ ]ment of my husband, wife, or parent.2. I elect to cancel my present enroll- (b) I am covered by a health insurance plan which is not under the Health [X]ment under the Health Benefits Act. Benefits Act.(c) Another reason [ ]PART DPART EALL WHOREGISTERMUST FILLIN THIS PART.Robert T. Shaw June 20, 19601. NAME AND ADDRESS OF EMPLOYEE'S OFFICE 2. DATE OF EVENT WHICH PERMITS CHANGE 3. EMPLOYEE'S SIGNATUREPART FTO BECOMPLETEDBYAGENCY.4. EMPLOYING OFFICE 5. PERSONNEL OFFICE NO. 6. PERSONNEL ACTION (When and Date)REMARKSFOR USE ONLYBY AGENCIESAND AUNUITANTSWARNING. - Any intentional false statement inthis application or willful misrepresentation relatingthereto is a violation of the law punishable by afine of not more than $10,000 or imprisonment ofnot more than 5 years, or both. (18 U.S.C. 1001).APR., 1963